Information Collection

OPTN Membership Application for Heart Transplant Program

IC 226684 under ICR 202512-0915-001 · OMB 0915-0184.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 OPTN Membership Application for Heart Transplant Program	Form and Instruction
Form 5 OPTN Membership Application for Heart Transplant Programs OPTN Membership Application for Heart Transplant Program	Form and Instruction
5 OPTN Membership Application for Heart Transplant Program 05_OPTN Membership Application for Heart Transplant Programs_CLEAN.docx	Form and Instruction
5 OPTN Membership Application for Heart Transplant Program 05_OPTN Membership Application for Heart Transplant Programs_CLEAN.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

OPTN Membership Application for Heart Transplant Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Organ Procurement and Transplantation Network (OPTN)/ Scientific Registry of Transplant Recipients (SRTR) Data System, HHS/ HRSA/HSB/DoT, 09-15-0055

FR Citation: 87 FR 46967

Number of Respondents: 155

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	39	-10	49
Annual IC Time Burden (Hours)	656	-349	1,005
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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